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Journal Article > Commentary
Elhence P, Veena S, Sharma RK, Chaudhary RK. Transfusion. 2010;50:2772-2777.
This case review discusses how root cause analysis of human and systems failures can identify areas for improvement to prevent clinical adverse events.
Journal Article > Study
Kaufman RM, Dinh A, Cohn CS, et al; BEST Collaborative. Transfusion. 2019;59:972-980.
Wrong-patient errors in blood transfusion can lead to serious patient harm. Research has shown that use of barcodes to ensure correct patient identification can reduce medication errors, but less is known about barcoding in transfusion management. This pre–post study examined the impact of barcode labeling on the rate of wrong blood in tube errors. Investigators found that use of barcoding improved the accuracy of labels on blood samples and samples that had even minor labeling errors had an increased chance of misidentifying the patient. The authors conclude that the results support the use of barcoding and the exclusion of blood samples with even minor labeling errors in order to ensure safe blood transfusion. An accompanying editorial delineates the complex workflow, hardware, and software required to implement barcoding for transfusion. A past WebM&M commentary discussed an incident involving a mislabeled blood specimen.